CLM-2026-008433
Meadow Imaging Center, Radiology. Service 2025-11-27 at outpatient hospital (POS 22). Received 2026-01-02.
Member
Resolved through the identity graph
- Member
- Martha Weaver
- Member ID
- UHC-63216-91
- Date of birth
- 1978-08-11
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-407497
- Relationship
- Spouse, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1307
- Coverage period
- 2025-06-01 to present
- Deductible
- $1,023.84 of $1,500.0068%
- Out-of-pocket maximum
- $1,396.61 of $6,000.0023%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 4402940280
- Network
- In network
- Rendering NPI
- 4402940280
- Location
- San Diego, CA · TIN 30-5345877
- Authorisation / referral
- PA2025201060 / none
Service lines
UB-04: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 74177 rev 0350 | CT abdomen and pelvis with contrast | 59 | 1 | 1 | $2,088.00 | $1,148.40 | — | — | Review |
| 2 | 70553 rev 0610 | MRI brain with and without contrast | 59 | 1 | 1,2 | $2,091.00 | $1,150.05 | — | — | Review |
| Totals | $4,179.00 | $2,298.45 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
- Patient account
- PA-938438
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-000625 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2025-11-27: - (PPO), effective 2025-06-01. | |
| Timely filing | Pass | Received 36 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025201060 on file for 74177, 70553. | |
| Provider network | Pass | In-network provider Meadow Imaging Center (4402940280). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Meadow Imaging Center2025-11-27 09:59
Patient seen for chest pain, unspecified. Separate procedure performed at a distinct anatomical site during the same encounter; see operative note for site detail.
- SystemSystem: Claims system2026-01-02 01:24
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
Attachments
Documents received with the claim
- Prior auth letterPA2025201060_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2025-11-27 to 2026-02-25.
- Itemized billitemized_PA-938438.pdf5 pages
Itemised statement totalling $4179.00 across 2 lines.
- Medical recordrecords_PA-938438.pdf20 pages
Operative note describing procedures at two distinct anatomical sites.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
- AI recommendationApproved2026-10-21 14:05The claim is for an in-network provider with a verified member identity and active coverage. The service was performed within the timely filing limit and has a valid prior authorization. The provider has used modifier 59 to indicate that the procedures were performed at distinct anatomical sites, which is supported by the operative note. The claim is within the auto-adjudication ceiling and all required documentation is present. The NCCI edit was flagged, but the operative note confirms the distinct procedural services, allowing for the approval of the claim.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:05 · 9b8533e8
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-026203 | 2026-04-07 | Riverside Internal Medicine Associates | $327.00 | Approved |
| CLM-2026-022843 | 2026-01-13 | Unity Internal Medicine Associates | $260.00 | Approved |
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
The claim is for an in-network provider with a verified member identity and active coverage. The service was performed within the timely filing limit and has a valid prior authorization. The provider has used modifier 59 to indicate that the procedures were performed at distinct anatomical sites, which is supported by the operative note. The claim is within the auto-adjudication ceiling and all required documentation is present. The NCCI edit was flagged, but the operative note confirms the distinct procedural services, allowing for the approval of the claim.
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Modifier 59 supported: distinct anatomical site documented.